Meduloblastoma é um câncer do sistema nervoso central, altamente invasivo, de origem embrionária, localizado no cerebelo. É mais comum em crianças e corresponde a aproximadamente 20% de todos os tumores intracranianos pediátricos. Os tratamentos mais utilizados são cirurgia e quimioterapia, sendo que a radioterapia é aplicada somente em crianças com mais de 3 anos devido aos seus efeitos colaterais. Diversos estudos têm mostrado o papel do NF-B na regulação de genes envolvidos com o processo neoplásico. NF-B é um fator de transcrição chave na regulação da resposta imune e no processo de inflamação e está envolvido na regulação da transcrição de um grande número de genes relacionados ao processo de tumorigênese, além de ser constitutivamente ativo em diversos tipos de câncer, sendo um importante potencial alvo terapêutico. O DHMEQ (Dehidroximetilepoxiquinomicina) é uma droga que inibe a translocação do NF-B do citoplasma para o núcleo, inibindo assim a sua atuação como ativador transcricional. Vários trabalhos tem mostrado os efeitos antineoplásicos do DHMEQ em inúmeros tipos tumorais, entretanto, não há trabalhos que evidenciem esses efeitos em meduloblastoma. Assim, o presente estudo objetivou avaliar os efeitos dessa droga nas linhagens UW402, UW473 e ONS-76 de meduloblastoma pediátrico através de estudos funcionais e moleculares. Os resultados de proliferação demostraram uma significativa diminuição do crescimento celular nas linhagens de meduloblastoma, inibindo cerca de 80, 70 e 60% nas linhagens UW402, UW473 e ONS-76, respectivamente, na dose de 20 g/mL, e apresentou um IC50 de 10g/mL em 48h para as linhagens UW402 e UW473 e em 72h na linhagem ONS-76. Adicionalmente, elevou o nível de apoptose para 50, 17 e 31% nessas linhagens, respectivamente, inibiu fortemente a capacidade clonogênica, a migração e a invasão celular nas três linhagens e foi sinérgico na combinação com outros quimioterápicos em grande parte dos pontos de combinação, além de radiossensibilizar fortemente as três linhagens. Os resultados são congruentes com o potencial efeito antitumoral de DHMEQ. / Medulloblastoma is a cancer of the central nervous system, highly invasive, of embryonic origin, located in the cerebellum. It is more common among children and accounts for approximately 20% of all pediatric intracranial tumors. The most common treatments are surgery and chemotherapy, and radiotherapy is only to children older than 3 years old due to its side effects. Several studies have demonstrated the role of NF-B in the regulation of genes involved in the neoplastic process. NF-B is a key transcription factor in the regulation of immune response and inflammation process, and it is involved in the transcriptional regulation of a large number of genes related to the tumorigenesis process, and constitutively active in many types of cancer, being an important potential therapeutic target. DHMEQ (Dehidroximetilepoxiquinomicina) is a drug that inhibits the translocation of NF-B from the cytoplasm to the nucleus, thus inhibiting its activity as a transcriptional activator. Several studies have shown the antineoplastic effects of DHMEQ in numerous tumor types, however, there is no surveys that have tested their effects in medulloblastoma. Thus, the present study aimed to evaluate the effects of this drug in UW402, UW473 and ONS-76 pediatric medulloblastoma cell lines through functional and molecular studies. The proliferation test results demonstrated a significant decrease in the cell growth in the medulloblastoma cell lines, inhibiting approximately 80, 70 and 60% for UW402, UW473 and ONS-76, respectively, at a dose of 20g/mL, and showed an IC50 of 10g/mL at 48h for UW402 and UW473 and at 72h in ONS-76. Additionally, increased the level of apoptosis to 50, 17 and 31% in these cell lines, respectively, strongly inhibited the clonogenic capacity, the migration and cell invasion in the three lines and it was synergistic in combination with other chemotherapeutic agents in most combination points, and radiosensitization strongly the three cell lines. The results are congruent with the potential antitumor effect of DHMEQ.

Prognostic factors come in a variety of forms and may be patient, tumour or environmental related. This thesis examines the interaction of prognostic factors for a variety of tumour types. It particularly focuses on single nucleotide polymorphisms (SNPs) of the vascular endothelial growth factor (VEGF) gene. The first section on meningiomas describes the frequency of sex steroid receptors in meningiomas. In this study, absence of progesterone receptors is associated with high tumour grade and male gender. Tumours that are progesterone receptor negative have an odds ratio for recurrence of 5.Choroid plexus carcinomas are aggressive malignant tumours generally occurring in young children. Gross total surgical resection has been shown to be a highly significant factor in tumour recurrence and survival. This study describes a treatment paradigm of neoadjuvant ICE chemotherapy in these children which decreases the vascularity and increase the chance of a complete removal. The operative blood loss with this regimen is reduced to 0.22 blood volumes from 1.11 blood volumes without neoadjuvant chemotherapy. The VEGF gene is highly polymorphic and SNPs of the region have previously been shown to influence VEGF protein expression. This study looks at cohorts of both adult gliomas and a variety of paediatric brain tumours; comparing them to controls. There are several associations described between the development of certain tumours and specific SNP genotypes. In addition to this, certain genotypes and haplotypes have an influence on survival of adult grade 2 astrocytomas and paediatric medulloblastomas and ependymomas. There are consistent themes to the prognostic genotypes throughout both the adult and the paediatric tumours.Prognostic factors come in a variety forms as described in this thesis. It is vital to understand the complex interaction between factors to best utilise them for the benefit of patients.

Le médulloblastome est la plus fréquente des tumeurs pédiatriques malignes du cerveau et est divisé en quatre sous-groupes moléculaires. Le groupe Sonic Hedgehog (SHH), caractérisé par l’activation de la voie SHH, présente une surexpression du facteur de transcription basique hélice-boucle-hélice Atoh1. Atoh1 est essentiel pour le développement du cervelet et plus spécifiquement pour la formation des précurseurs des cellules granulaires, qui sont aussi la cellule d’origine du médulloblastome SHH. Dans le médulloblastome SHH, Atoh1 agit comme un facteur pro-tumoral en collaboration avec la voie SHH. De plus, l’inhibition des niveaux protéiques d’Atoh1 inhibe la prolifération tumorale in vitro et in vivo. Etant donnée l’importance de la protéine Atoh1 dans la formation du médulloblastome SHH, Atoh1 pourrait être une cible thérapeutique potentielle pour traiter le médulloblastome SHH. Cependant, les mécanismes de régulation d’Atoh1 sont encore mal connus.Les modifications post-traductionnelles sont connues pour réguler les niveaux protéiques dans les cellules. Plusieurs types de modifications régulent la dégradation protéique et elles incluent l’ubiquitination et la phosphorylation. Nous avons décidé de nous concentrer dans un premier temps sur le rôle potentiel de la phosphorylation d’Atoh1 sur sa fonction et régulation durant le développement du cervelet et la formation de médulloblastome.Par une analyse de spectrométrie de masse, nous avons identifié douze sites de phosphorylation sur la protéine Atoh1. Parmi ces douze sites, seulement deux, la sérine 328 (S328) et la sérine 339 (S339), sont importantes pour la stabilité et la fonction de la protéine. En effet, les deux mutants de phosphorylation spécifiques de ces deux sites, Atoh1-S328A et Atoh1-S339A, ont une demi-vie plus longue ainsi qu’une activité transcriptionnelle augmentée dans les précurseurs des cellules granulaires par rapport à la forme sauvage d’Atoh1. Nous avons ensuite réalisé une purification d’affinité en tandem différentielle suivie par une analyse par la technologie d’identification protéique multidimensionnelle (MudPIT) pour définir les partenaires phospho-spécifiques d’Atoh1. Nous avons découvert que l’ubiquitine ligase E3 Huwe1 est responsable de la dégradation d’Atoh1 de manière phospho-dépendante dans les progéniteurs des cellules granulaires. Nous avons aussi montré que SHH protège Atoh1 de la dégradation médiée par Huwe1 par l’intermédiaire des phosphatases de la famille des PP2A. De manière importante, ce mécanisme de régulation d’Atoh1 est nécessaire au bon développement du cervelet. De plus, dans le contexte tumoral, un faible niveau d’ARNm d’HUWE1 est associé à une mauvaise survie chez les patients ayant un medulloblastome SHH.Au vu de ces résultats, nous souhaitons étudier plus en détail le rôle de la phosphorylation d’Atoh1 ainsi que la contribution de ce nouveau mécanisme dans le médulloblastome. Nous souhaiterions ainsi exploiter nos résultats pour développer de nouvelles stratégies thérapeutiques dans le médulloblastome SHH. / Medulloblastoma (MB) is the most common pediatric malignant brain tumor and is divided in four subgroups by gene profiling. The well-known subgroup harboring an activation of the Sonic Hedgehog (SHH) pathway shows an upregulation of the proneural basic helix-loop-helix transcription factor Atoh1. Atoh1 is essential for cerebellum development and more specifically for the formation of the granule neuronal progenitors (GNPs), which are the cells of origin of SHH induced MB. In tumoral context, Atoh1 acts as a pro-tumor factor in cooperation with SHH pathway. In addition, the inhibition of Atoh1 protein level prevents MB proliferation in vitro and in vivo. Thus, given the strong implication of Atoh1 protein in MB formation, Atoh1 seems to be a potential therapeutic target to treat SHH MB. However, up to date, mechanisms underlying its regulation remain to be elucidated. Posttranslational modifications are known to regulate protein levels in cells. Several modifications regulate protein turnover including the two most prominent, ubiquitination and phosphorylation. We decided to focus primarily our study on a potential role of Atoh1’s phosphorylation on its function and regulation both during cerebellar development and MB genesis. Using mass spectrometry analysis, we identified twelve phosphorylation sites on Atoh1 protein. Among them, only two, the serine 328 (S328) and serine 339 (S339), were critical for Atoh1 stability and function. The two single phospho-deficient mutants, Atoh1-S328A and Atoh1-S339A, displayed a longer half-life and increased transcriptional activity in granule neuron progenitors when compared to the wild-type form of Atoh1. Next, we employed differential tandem affinity purification followed by Multidimensional Protein Identification Technology (MudPIT) analysis to define Atoh1 phospho-specific partners. We uncovered that the E3 ubiquitin ligase Huwe1 is responsible for Atoh1 degradation in a phospho-dependent manner in granule neuron progenitors. We also discovered that SHH protects Atoh1 against its degradation mediated by Huwe1 through the phosphatases of PP2A family. Importantly, this machinery is required for proper cerebellar development and we highlighted that low levels of HUWE1 are associated with a poor prognosis in patient harboring a SHH medulloblastoma.Given this data, we wish to dissect the role of Atoh1 phosphorylation, and the contribution of this new pathway in MB. We anticipate exploiting our findings to develop new therapeutic strategies in SHH MB.

Le facteur de transcription à homéodomaine Otx2 est essentiel au développement du système nerveux, et en particulier du cervelet, où il est exprimé dans les précurseurs des neurones granulaires (PCGs). Au cours du développement, les PCGs passent par des périodes prolifératives très intenses qui les exposent à la transformation tumorale. Ces cellules seraient ainsi à l’origine de la formation des cancers du cervelet, les médulloblastomes (MBs). Une altération génétique particulière est cependant retrouvée dans plus de 75% des MBs : la surexpression d’Otx2. Cette thèse vise à comprendre le rôle d’Otx2 dans le contrôle de la prolifération dans un contexte normal ou tumoral. D’abord, nous avons entrepris d’identifier et d’isoler ces précurseurs à partir de souriceaux, afin d’analyser leur caractéristiques prolifératives. Nos résultats ont montré que les cellules « Otx2+ » contiennent une fraction proliférative plus importante que les cellules « Otx2-». L’analyse du cycle cellulaire des cellules « Otx2+» montre également que ces dernières présentent des propriétés prolifératives distinctes. Ensuite, nous avons mis en oeuvre une approche de gain et de perte de fonction d’Otx2 dans une lignée de MBs exprimant Otx2 (HD-MB03). Nos résultats indiquent que la surexpression d’Otx2 stimule la prolifération de cette lignée, alors que sa perte de fonction la diminue. Enfin, Nous avons identifié par des analyses protéomiques par spectrométrie de masse des partenaires impliqués dans la régulation du cycle cellulaire, en particulier au niveau des phases S et G2M. Ces résultats suggèrent un mécanisme d’action unique d’Otx2 dans la régulation du cycle cellulaire dans le cervelet et les MBs / The homeobox transcription factor Otx2 is essential for the development of the central nervous system. During cerebellum development, Otx2 is expressed by granule cell precursors (GCPs), which have a high proliferation rate. Deregulation of GCPs proliferation may favor oncogenic processes, as seems to occur in medulloblastoma (MB), a malignant and invasive tumor of the cerebellum. A recurrent genetic alteration in medulloblastoma is the overexpression of Otx2 in 75% of the cases. The objective of this thesis is to study the role of Otx2 in the control of proliferation during normal and oncogenic development of the cerebellum. First, we investigated the role of Otx2 in the control of GCPs proliferation. Our results show that Otx2+ GCPs have an increased proliferation rate compared to «Otx2-» GCPs. In the second part of this work, we tested the oncogenic potential of Otx2 using the medulloblastoma cell line HD-MB03. We performed gain and loss of function experiments to analyze the effect of Otx2 expression on the proliferation of this cell line. Our results indicate that the overexpression of Otx2 increases the proliferation rate of HD-MB03 tumor cells. Conversely, Otx2 silencing significantly decreases it. Finally, to shed the light on the mechanism of action of Otx2 in the control of proliferation in cerebellum and medulloblastoma, we analyzed Otx2 protein partners in both cases by mass spectrometry analysis after immunoprecipating Otx2-protein complexes. We identified several protein partners that play an important role in cell cycle regulation, more specifically in S and G2M phases. Our project shows a pro-proliferative effect of Otx2 in cerebellum and medulloblastoma

In the search for new genes that are regulated by thyroid hormone, DISP3, a new member of the SSD (sterol-sensing domain) protein family, has been identified. Expression analysis showed that DISP3 is expressed in cells of neural origin, and our previous results indicate that overexpression of this gene affects cell proliferation and differentiation. Oncomine database analysis also showed that DISP3 expression is increased in medulloblastomas, the most common malignancies of the central nervous system in children. The subject of this diploma thesis is studying the effect of increased DISP3 levels on cell apoptosis and cell ability to form a colony. Cell lines derived from medulloblastomas were used in the work. We compared the expression levels of the DISP3 gene in different medulloblastoma lines by quantitative PCR and selected a line with low expression of this gene for further experiments. Some medulloblastoma cell lines can form neurospheres when cultured in serum-free medium. Using quantitative PCR, we compared the expression levels of neural markers in cells cultured both as neurospheres and as adherent cells. By transfecting cells with a plasmid overexpressing DISP3, we prepared cells with increased levels of this gene. We induced apoptosis by radiation at different doses. Apoptosis was...

Le médulloblastome (MB), une tumeur formée à partir du cervelet en développement, est l’un des cancers pédiatriques malins les plus fréquents. Des profils d’expression géniques ont montré l’existence de quatre groupes distincts de MB qui présentent des profils moléculaires et des pronostics différents. Parmi ces groupes, l’un d’entre eux est caractérisé par une activation de la voie de signalisation Sonic Hedgehog (SHH). Ce groupe de MB provient des précurseurs de neurones en grain lors du développement cérébelleux. Les traitements actuels comprennent la chirurgie, la chimiothérapie ainsi que la radiothérapie, ce qui a pour effet d’altérer les capacités cognitives et sociales des survivants. Ainsi, des efforts considérables ont été mis en œuvre dans le but de trouver des cibles thérapeutiques afin de bloquer spécifiquement les mécanismes tumorigéniques sans affecter le développement normal. De récentes analyses à grande échelle ont révélé le rôle crucial de mécanismes épigénétiques, et en particulier dans le groupe SHH, dans lequel la perte de fonction d’un certain nombre de modificateurs chromatiniens a été identifiée. Ainsi, l'objectif principal de ma thèse est d'étudier l'implication de potentiels candidats modificateur chromatinien, à la fois au cours du développement cérébelleux et lors du MB SHH. Nous avons concentré notre étude sur plusieurs modificateurs de la chromatine qui ont été trouvés mutés dans les MB SHH humains. Nous avons commencé l’étude avec trois modificateurs chromatiniens sélectionnés selon (i) leur impact sur la survie, (ii) leur expression au cours du développement du cervelet, (iii) leur expression dans les MB SHH humains et nous sommes finalement concentré sur un.Afin d'étudier ce candidat, un objectif important de ma thèse a été de développer des outils fiables. Dans ce contexte, nous avons développé des modèles de souris knock-out conditionnelles et le système CRISPR-cas9 dans le développement cérébelleux postnatal afin d'étudier l'impact de la perte du candidat à la fois dans le développement du cervelet et dans le MB SHH. Ensuite, nous nous sommes intéressés aux mécanismes moléculaires contrôlés par ce modificateur de la chromatine. Plus précisément, nous avons défini (i) l’interactome, et (ii) des cibles transcriptionnelles spécifiques qui nous ont aidé à comprendre comment une protéine impliquée dans la modification de la chromatine peut favoriser l’état tumoral. En conclusion, ces travaux permettent de mettre en évidence comment la perte de la fonction de modificateur chromatinien spécifique peut différemment affecter le destin cellulaire dans le développement normal cérébelleux et dans le MB SHH et soulève la question d’une prise en charge plus personnalisée des patients atteints de MB SHH. / Medulloblastoma (MB), a tumor arising from the developing cerebellum, is one of the most common malignant pediatric brain tumors. Gene expression profiling showed the existence of four groups of MB with distinct molecular profiles and patient outcomes. Among these groups, one of them is associated with an activation of the Sonic Hedgehog (SHH) pathway.This specific group is thought to arise from cerebellar Granule Neuron Progenitors (GNPs) during cerebellar development. The actual treatment is heavy and consists of surgery, chemotherapy as well as radiotherapy impairing social and cognitive ability of survivors. Thus, considerable effort has been made in order to find drug targets that would specifically block tumorigenic mechanisms without affecting normal development.Recent large scale analysis revealed the crucial role of epigenetic mechanisms, and especially in the SHH group of MB in which loss of function mutation of several chromatin modifiers has been identified. Thus, the main goal of my PhD is to study the involvement of potential candidate chromatin modifiers both during cerebellar development and in SHH MB.We focused our study on several chromatin modifiers that were found mutated in human SHH MB. We began to study three chromatin modifiers that were selected according to (i) their impact on survival, (ii) their expression during cerebellar development, (iii) their expression in human SHH MB and finally we selected one for further functional validation.In order to study this candidate, one important goal of my PhD has been to develop reliable tools. In that context, we developed conditional knock-out mice models and the CRISPR-Cas9 system in postnatal cerebellar development in order to study the impact of the loss of this chromatin modifier both in cerebellar development and SHH MB initiation. Then, we investigated the molecular mechanisms controlled by this chromatin modifier. In particular, we defined (i) the interactome, and (ii) specific target genes that helped us understanding how a protein implicated in chromatin modification can favor tumors. In conclusion, this work provides insights into how the loss of function of a specific chromatin modifier can differentially affect cell fate in the context of normal cerebellar development and in SHH MB, stressing the question of a more personalized patient care.

Pendant le développement du cervelet, les progéniteurs des neurones granulaires (PNG) nécessitent la présence du cil primaire pour proliférer en réponse à Sonic Hedgehog (SHH). En effet, la prolifération dérégulée des PNGs peut conduire à la formation d'une tumeur pédiatrique maligne appelée SHH-médulloblastome (MB), de ce fait comprendre comment le cil primaire est régulé dans les PNGs est crucial.Nous montrons que le facteur de transcription Atoh1 contrôle la présence du cil primaire dans les PNGs in vitro et in vivo. En particulier, la suppression du cil primaire par l’inactivation génétique de gènes impliqués dans la ciliogenèse (par exemple, Kif3a ou Ift88) empêche Atoh1 de maintenir les PNGs en prolifération, ce qui indique qu’Atoh1 favorise l’expansion des PNGs en maintenant la présence du cil primaire. D’un point de vue moléculaire, Atoh1 contrôle la formation du cil primaire en régulant le bon positionnement peri-centrosomal des satellites centriolaires (SC), complexes protéiques essentiels pour la ciliogenèse. L'inactivation de Atoh1 dans les PNGs perturbe en effet la distribution subcellulaire des SCs, altérant ainsi inévitablement la ciliogenèse. Cette nouvelle fonction de Atoh1 est gouvernée par la régulation transcriptionnelle directe d'un composant clé des SCs, Cep131. L’expression ectopique de Cep131 dans les PNGs restore les effets liés à l'inactivation d'Atoh1, rétablissant la localisation correcte du SC et comme conséquence la présence d’un cil primaire.De plus, nous avons montré que cette voie Atoh1-SC-cil primaire-SHH contrôlant la prolifération des PNGs est également conservée dans le contexte du SHH-MB, où Atoh1 est surexprimée et essentielle pour sa formation et sa maintenance.Ces données révèlent un mécanisme par lequel la ciliogenèse est régulée dans des progéniteurs de neurones, offrant de nouvelles informations sur la neurogenèse dans le cervelet et sur la pathogenèse du SHH-MB. / Cerebellar granule neuron progenitors (GNPs) require the primary cilium to proliferate in response to Sonic Hedgehog (SHH) during cerebellar development. As aberrant proliferation of GNPs may lead to SHH-type medulloblastoma (SHH-MB), a pediatric brain tumor, understanding which mechanisms control ciliogenesis in GNPs represents a major interest in the field. Here, we show that the proneural bHLH transcription factor Atoh1 controls the presence of primary cilia in GNPs both in vitro and in vivo, thus maintaining GNPs responsive to the mitogenic effects of SHH. Indeed, loss of primary cilia induced via knockdown of specific ciliary components (e.g. Kif3a and Ift88) abolishes the ability of Atoh1 to keep GNPs in proliferation in vivo. Mechanistically, Atoh1 controls ciliogenesis by regulating the proper peri-centrosomal clustering of centriolar satellites (CS), large multiprotein complexes working as essential machineries for ciliogenesis. Knockdown of Atoh1 in GNPs perturbs CS subcellular distribution, leading to impairment of ciliogenesis. Luciferase reporter assays and chromatin immunoprecipitation experiments indicate that Atoh1 can directly regulate the expression of Cep131, a key CS core component. Importantly, ectopic expression of Cep131 in GNPs depleted of Atoh1, is sufficient to restore proper CS localization and consequent primary cilia formation, indicating that the Atoh1-Cep131-CS axis is responsible for ciliogenesis in GNPs.In addition, we further demonstrated that these functions of Atoh1 are conserved in the context of SHH-MB, where Atoh1 is typically overexpressed and acts as a lineage-dependent transcription factor.These data reveal a mechanism whereby ciliogenesis is regulated in neuron progenitors providing novel insights into cerebellar neurogenesis and pathogenesis of SHH-MB.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21302号 / 医博第4391号 / 新制||医||1030(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 生田 宏一, 教授 椛島 健治, 教授 杉田 昌彦 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Pediatric medulloblastoma (MB) is a cerebellar brain tumor namely characterized by its origination in early development, as early as embryogenesis. MB is thought to originate from the highly heterogeneous granular neuron precursor (GNP) cell population that resides within the rhombic lip of the dorsal hindbrain region, and is particularly susceptible to the effects of the oncogenic Sonic Hedgehog (SHH) signaling pathway. Patched 1 (Ptch1), typically a transmembrane SHH pathway tumor suppressor gene, is mutated in 20% of MB cases, otherwise known as SHH-group MBs. This mutation in MB presents as a loss of heterozygosity (LOH), where the wild type allele of Ptch 1 is deleted. Ptch 1 receptor silencing activates downstream target genes such as proto-oncogene Smoothened (Smo) and allows for the initiation of tumorigenesis. However, the molecular basis for Ptch1 LOH in MB remains elusive. We have discovered a cancer-testis antigen, Protamine 1 (Prm 1), that is present in the Ptch 1 locus in SHH-group MB tumors. By utilization of the RNAscope technique, we confirm mRNA expression of Prm 1 in cerebellar tumor tissue, predominantly from tumor cells, but not in stromal cells. These studies reveal that tumor cells highjack the promoter of Ptch 1 to express Prm 1, promoting tumor progression. These findings establish the mechanism for Ptch 1 LOH in SHH-group MB, and provide the rationale to define the cell of origin for SHH group MB based on Prm 1 expression. / Biomedical Sciences

Medulloblastoma is the most frequent malignant brain tumor in children. During the last decades, the therapeutic landscape has changed significantly with craniospinal irradiation as the backbone of treatment. Survival times have increased and treatments were stratified according to clinical and later molecular risk factors. In this review, current evidence regarding the efficacy and toxicity of radiotherapy in medulloblastoma is summarized and discussed mainly based on data of controlled trials. Current concepts and future perspectives based on current risk classification are outlined. With the introduction of CSI, medulloblastoma has become a curable disease. Due to combination with chemotherapy, survival rates have increased significantly, allowing for a reduction in radiation dose and a decrease of toxicity in low- and standard-risk patients. Furthermore, modern radiotherapy techniques are able to avoid side effects in a fragile patient population. However, high-risk patients remain with relevant mortality and many patients still suffer from treatment related toxicity. Treatment needs to be continually refined with regard to more efficacious combinatorial treatment in the future.